Based on the information provided:- The patient has palpitations, chest discomfort and tachycardia- The monitor shows wide-complex tachycardia (likely ventricular tachycardia)- The patient's condition is deteriorating with diaphoresis and dropping blood pressureThe immediate next step in this emergency situation should be to perform immediate electrical cardioversion to terminate the potentially life-threatening arrhythmia. Obtaining a 12-lead EKG can be done concurrently but should not delay cardioversion.The appropriate response is: "Perform immediate electrical cardioversion
The document outlines the treatment algorithm for pulseless arrest, including initiating BLS, attaching an AED or monitor if available, checking the rhythm, and administering shocks if VF/VT is detected or continuing CPR and epinephrine if
Similaire à Based on the information provided:- The patient has palpitations, chest discomfort and tachycardia- The monitor shows wide-complex tachycardia (likely ventricular tachycardia)- The patient's condition is deteriorating with diaphoresis and dropping blood pressureThe immediate next step in this emergency situation should be to perform immediate electrical cardioversion to terminate the potentially life-threatening arrhythmia. Obtaining a 12-lead EKG can be done concurrently but should not delay cardioversion.The appropriate response is: "Perform immediate electrical cardioversion
Similaire à Based on the information provided:- The patient has palpitations, chest discomfort and tachycardia- The monitor shows wide-complex tachycardia (likely ventricular tachycardia)- The patient's condition is deteriorating with diaphoresis and dropping blood pressureThe immediate next step in this emergency situation should be to perform immediate electrical cardioversion to terminate the potentially life-threatening arrhythmia. Obtaining a 12-lead EKG can be done concurrently but should not delay cardioversion.The appropriate response is: "Perform immediate electrical cardioversion (20)
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Based on the information provided:- The patient has palpitations, chest discomfort and tachycardia- The monitor shows wide-complex tachycardia (likely ventricular tachycardia)- The patient's condition is deteriorating with diaphoresis and dropping blood pressureThe immediate next step in this emergency situation should be to perform immediate electrical cardioversion to terminate the potentially life-threatening arrhythmia. Obtaining a 12-lead EKG can be done concurrently but should not delay cardioversion.The appropriate response is: "Perform immediate electrical cardioversion
1. 01
WINTER
2005
Circulation
ACLS
Template
Panita Worapratya
Emergency Department
Prince of Songkhla University
2. Effective Chest compression
Goals How to achieve
Push 100/min
Push
hard & Deep 1/3 of chest wall
fast
Fully recoil
Fully
Don’t let hands off the chest wall
recoil
Minimized
interruption
Avoid fatique
Resume CPR
No pause for check pulse
3. WINTER
2005
Circulation
ACLS Template
Pulseless Arrest
Panita Worapratya
Emergency Department
Prince of Songkhla University
4. Pulseless Arrest
•BLS algorithm, Call for help ,give CPR
•Give oxygen when avialable
•Attach moniter/ AED when avialable
Check rhythm. Shockable ?
5. Pulseless Arrest
•BLS algorithm, Call for help ,give CPR
•Give oxygen when avialable
•Attach moniter/ AED when avialable
Check rhythm. Shockable ?
VF/VT Asystole/PEA
Resume CPR immediately
I.V/I.O access, given vasopressor
• Epinephrine 1 mg I.V/ I.O q 3-5 min
•Vasopressin 40 U I.V/I.O to replace
epinerphine
•Consider atropine 1 mg I.V/I.O for
asystole or slow PEA
6. Pulseless Arrest
•BLS algorithm, Call for help ,give CPR
•Give oxygen when avialable
•Attach moniter/ AED when avialable
Check rhythm. Shockable ?
VF/VT Asystole/PEA
Give 1 shock
•Manual biphasic 200J
•Monophasic 300 J
•AED when avialable
Resume CPR immediately
Check rhythm. Shockable ?
7. Check rhythm. Shockable ?
VF/VT Asystole/PEA
Give 1 shock
•Manual biphasic 200J
•Monophasic 300 J
•AED when avialable
Resume CPR immediately
Check rhythm. Shockable ?
Continue CPR while defibrilator is charging
Give 1 shock
•Manual biphasic 200J
•Monophasic 300 J
•AED when avialable
Resume CPR immediately after shock
When I.V or I.O access give vasopress
Epinephrine 1 mg I.V/I.O q 3-5 min
Or one dose of vasopressin 40 U I.V/I.O
8. Continue CPR while defibrilator is charging
Give 1 shock
Resume CPR immediately after shock
Epinephrine 1 mg I.V/I.O q 3-5 min
Check rhythm. Shockable ?
Continue CPR while defibrilator is charging
Give 1 shock
Resume CPR immediately after shock
Epinephrine 1 mg I.V/I.O q 3-5 min
Consider antiarrythmic drug
•Amiodarone 300 mg I.V/I.O then 150 mg I.V
•Lidocaine 1-1.5 mg/kg I.V/I.O then 0.5-7.5 mg/kg I.V/I.O
•Consider MgSO4 1-2 g I.V/I.O
•After 5 cycle of CPR , look for 6H,5T
9. Questions
• ชายอายุ 55 ปี เป็นโรคหัวใจอยู่เดิม ถูกนาส่งร.พ ด้วยเรื่องหมดสติ ญาติให้
ประวัติว่าเป็นขณะออกกาลังกาย แรกรับ Unconsciousness, no
pulse. EKG เป็นดังรูป ท่านจะให้การรักษาอย่างไร
a. Chest compression
b. Atropine 1 amp iv stat
c. Synchronized cardioversion 100 J
d. Defibrillation 200 J
e. Search for 6H, 5T
pulseless VF : Defibrillation 200 J
10. Questions
• หญิงอายุ 45 ปี Underlying เป็น CA breat with distance
metastasis ญาติพบว่าตอนเช้าปลุกไม่ตื่น ตัวเย็น ซีดเขียว ไม่หายใจ
ไม่ทราบว่าตั้งแต่เมื่อใด แรกรับ Unconsciousness, no pulse.
EKG เป็นดังรูป ท่านจะให้การรักษาอย่างไร
a. Chest compression 5 cycle
b. Atropine 1 amp iv stat
c. Synchronized cardioversion 100 J
d. Defibrillation 200 J Asystole : CPR 5 cycle
e. Search for 6H, 5T
11. Questions
• ขณะที่ทีมกาลัง CPR ผู้ป่วยหญิงอายุ 68 ปี ไม่ทราบประวัติ มาด้วยไม่
รู้สึกตัว ได้ใส่ ET-Tube , i.v access, adrenaline 1 amp iv
q 3-5 min และ High quality CPR แล้วไม่ดขึ้น EKG ยังคงเป็น
ี
ดังรูป หลังจากท่านได้ทา Defibrillation ไปแล้ว 3 ครั้ง ท่านจะให้การ
รักษาอย่างไรต่อ ? (อาจเลือกได้มากกว่า 1 ข้อ)
a. Antiarrhythmic drug Refractory VT :
b. NaHCO3 50 mEq •Amiodarone 300 mg i.v/i.o
c. Escalating dose epinephrine 3 mg
•6H, 5T
d. Search for 6H, 5T
17. Questions
• You are arrive on scene to fine CPR is in progress. Nursing staff
report that the patient was recovering form pulmonary embolism
and suddenly collapsed. There is no pulse or spontaneous
respiration. High quallity CPR is in progress and effetive circulation
is being provided with bag mask. An i.v is establish, you would
now…?
a. Give atropine 1 mg i.v
b. Give NaHCO3 1 amp iv
c. Immediate CPR
d. Immediate endotracheal intubation
e. Initiate transcutaneous pacing
19. Questions
• ผู้ป่วยชายอายุ 35 ปี เป็นช่างซ่อมเสาไฟฟ้า นาส่งร.พ เนื่องจากโดนไฟฟ้าแรงสูง
ช๊อต และตกจากที่สูง 5 เมตร ไม่รู้สกตัว แรกรับไม่มีสัญญาณชีพ Moniter
ึ
EKG เป็นดังรูป จงให้การรักษา
a. Give atropine 1 mg i.v
b. Give epineprhine 1 mg i.v
c. Give Synchronized cardioversion 100 J
d. Immediate Defibrillation 200J
e. Initiate transcutaneous pacing
20. WINTER
2005
Brady &
Template
Tacchycardia
Panita Worapratya
Emergency Department
Prince of Songkhla University
21. • 35 yr-old woman with palpitation, light headness and stable
tacchycardia. EKG as picture. An IV has been established. What drug
should be administered IV?
o Atropine 0.5 mg
o Lidocaine 1 mg/kg
o Epinephrine 2-10 µg/kg/min
o Adenosine 6 mg
22. WINTER
Template
67 Yr-old male ไม่รู้สึกตัวมา 30 min >V/S : BP 64/24,PR 30/min หลังจากท่านได้ใส่
ท่อช่วยหายใจ เปิดเส้นเลือด ติด monitor EKG แล้ว คลื่นไฟฟ้าหัวใจเป็นดังรูปท่านคิดว่าการกระทาใด
เหมาะสมที่สุด
o On external pacing
o Atropine 0.6 mg iv stat
o 7.5 % NaHCO3 1 amp iv stat
o 10% Ca-gluconate 1 amp iv stat
23. WINTER
Template
55 Yr-old female บ่นจุกแน่นหน้าอกที่ลิ้นปี่มา 1 ช.ม เป็นขณะพัก ประวัติว่าเคยไปตรวจที่คลินิค
แพทย์บอกว่าหัวใจโต V/S : BP 140/86 PR 87/min ,regular-full peripheral
pulse. EKG เป็นดังรูป ท่านจะทาอย่างไร
o ให้ ASA, ISDN, Morphine
o ให้ serial EKG ไปก่อน รอ cardiac enzyme
o Consult cardiologist ทันที สงสัย AMI
24. WINTER
Template
58 Yr-old male บ่นแน่นหน้าอก หน้ามืดจะเป็นลม 30 นาที V/S BP 90/60 PR 33/min
,sweating, look anxiousness. EKG เป็นดังรูป ท่านจะทาอย่างไร
o ให้ atropine 1 amp iv. stat
o ให้ serial EKG รอ cardiac enzyme
o Consult cardiologist ทันที สงสัย AMI
o ใส่ Transcutaneous pacing
25. WINTER
Template
61 Yr-old male หน้ามืด ขณะนั่งรับประทานอาหาร ไม่มจุกแน่นหน้าอก แต่มีใจสั่น V/S แรกรับ
ี
BP 95/57 PR 42/min , irregular, sweating ถามตอบไม่รู้เรื่อง
o ให้ atropine 1 amp iv. stat
o ให้ serial EKG รอ cardiac enzyme
o Consult cardiologist ทันที
o ใส่ Transcutaneous pacing
26. WINTER
Template
66 Yr-old male, underlying CAD with history of coronary bypass
graft. มาด้วยเป็นลมหมดสติ ไม่รู้สึกตัว BP วัดไม่ได้ ปลายมือปลายเท้าซีด เย็น
o ให้ adenosine 6 mg iv stat
o ให้ synchronized cardioversion 100 J
o ให้ cordarone 150 mg iv stat
o ให้ Defib 200 J
27. • 57 yr-old woman with palpitation, chest discomfort and tacchycardia.
The moniter as picture. She becomes diaphoretic and BP 80/60
mmHg. The next action is
o Obtain 12 lead EKG
o Perform immediate electrical cardioversion
o Establish IV and give sedation for electrical cardioversion
o Give amiodarone 300 mg IV push
28. • 27 ปีผู้ชาย อยู่ ๆ มีอาการใจสั่น หน้ามืด จะเป็นลม เหงื่อแตก ไม่เคยเป็นเช่นนี้มาก่อน
มาที่ ER ปลายมือปลายเท้าเย็น BP 120/84 PR 210 EKG เป็นดังรูป จงให้การรักษา
o Adenosine 6 mg iv stat
o Give amiodarone 300 mg IV push
o Perform immediate Defibrillation
o Establish IV and give sedation for synchronized cardioversion
29. 01
WINTER
Basic Template
EKG
Panita Worapratya
Emergency Department
Prince of Songkhla University
33. Rate & rhythm
WINTER
Template
• RR interval is 2 large block, rate = 150 beats/min (300/2)
• RR interval is 3 large block, rate = 100 beats/min (300/3)
• RR interval is 4 large block, rate = 75 beats/min (300/4)
34. Step 2 : P wave
WINTER
• Normal (sinus P wave) present?
Template
• Abnormal (non sinus P wave) present ?
35. Step 2 : P wave
WINTER
• No P wave : SVT or junctional
Template
36. Step 2 : P wave
WINTER
• Repalcement of P wave by other atrial wave?
Template
37. Step 3 : QRS complex
WINTER
Template
Stable
Wide QRS complex
V/S ?
Unstable Stable
Immediate
Cardioversion Consider common cause
•VT : Most common, especially
underlying heart disease
•SVT with pre-existing RBBB
•SVT with aberrant conduction
38. Differrentiate Wide QRS
WINTER
Wide QRS complex
Template
Excluded VT and
WPW !!
Typical RBB Typical LBB IVCD
RBB
LBB
•QRS wide > 0.11 s.
•QRS wide > 0.11 s •QRS wide > 0.12 s
•Neither typical RBB nor
•rSR' or rsR' in V1 •Upright (monophasic)
LBB present
•Wide terminal S wave in QRS in Lead I, V6 (เป็นตุด ไม่ใช่ LBB ก็ไม่ใช่ RBB ก็ไม่
๊
Lead I, V6 •Negative QRS in V1 เชิง)
39. Wide QRS differrentiation
Excluded VT and
Wide QRS complex WPW !!
Modified Brugada Criteria for VT
Question Answer
1. Is there AV dissociation? Yes = VT
( independent P/QRS, capture
beats, fusion beat)
2. Is there an RS in any No = VT
precordial lead?
3. Is there QRS onset to nadir of Yes = VT
S wave > 100 msec in any
precordial lead?
WPW 4. Are there morphologic criteria Yest = VT
•Short PR for VT in both V1 or V6?
• Delta wave 5. If no, SVT
• Wide QRS complex
40. Wide QRS differrentiation
Excluded VT and
Wide QRS complex WPW !!
Modified Brugada Criteria for VT
Question Answer
1. Is there AV dissociation? Yes = VT
( independent P/QRS, capture
beats, fusion beat)
2. Is there an RS in any No = VT
precordial lead?
AV dissociation 3. Is there QRS onset to nadir of Yes = VT
S wave > 100 msec in any
precordial lead?
4. Are there morphologic criteria Yest = VT
for VT in both V1 or V6?
5. If no, SVT
41. Wide QRS differrentiation
Excluded VT and
Wide QRS complex WPW !!
Modified Brugada Criteria for VT
Question Answer
1. Is there AV dissociation? Yes = VT
( independent P/QRS, capture
beats, fusion beat)
2. Is there an RS in any No = VT
precordial lead?
3. Is there QRS onset to nadir of Yes = VT
S wave > 100 msec in any
100 % specific for VT
precordial lead?
Sensitivity 26%
4. Are there morphologic criteria Yest = VT
for VT in both V1 or V6?
No RS wave in any precordial leads 5. If no, SVT
42. Wide QRS differrentiation
Excluded VT and
Wide QRS complex WPW !!
Modified Brugada Criteria for VT
Question Answer
1. Is there AV dissociation? Yes = VT
( independent P/QRS, capture
beats, fusion beat)
2. Is there an RS in any No = VT
precordial lead?
3. Is there QRS onset to nadir of Yes = VT
S wave > 160 msec in any
precordial lead?
4. Are there morphologic criteria Yest = VT
for VT in both V1,2 or V6?
5. If no, SVT
43. Wide QRS differrentiation
Excluded VT and
Wide QRS complex WPW !!
Modified Brugada Criteria for VT
Question Answer
1. Is there AV dissociation? Yes = VT
( independent P/QRS, capture
beats, fusion beat)
2. Is there an RS in any No = VT
precordial lead?
3. Is there QRS onset to nadir of Yes = VT
S wave > 100 msec in any
precordial lead?
4. Are there morphologic criteria Yest = VT
for VT in both V1,2 or V6?
5. If no, SVT
44. Wide QRS differrentiation
Excluded VT and
Wide QRS complex WPW !!
Modified Brugada Criteria for VT
Question Answer
1. Is there AV dissociation? Yes = VT
( independent P/QRS, capture
beats, fusion beat)
2. Is there an RS in any No = VT
precordial lead?
3. Is there QRS onset to nadir of Yes = VT
S wave > 100 msec in any
precordial lead?
4. Are there morphologic criteria Yest = VT
for VT in both V1,2 or V6?
5. If no, SVT
45.
46. Differrentiate Wide QRS
WINTER
Wide QRS complex
Template
Excluded VT and
WPW !!
Typical RBB Typical LBB IVCD
RBB
LBB
•QRS wide > 0.11 s.
•QRS wide > 0.11 s •QRS wide > 0.12 s
•Neither typical RBB nor
•rSR' or rsR' in V1 •Upright (monophasic)
LBB present
•Wide terminal S wave in QRS in Lead I, V6 (เป็นตุด ไม่ใช่ LBB ก็ไม่ใช่ RBB ก็ไม่
๊
Lead I, V6 •Negative QRS in V1 เชิง)
48. Step 4 : Analysis rhythm
Narrow complex tacchycardia
• Measure rate and rhythm
• Look for P wave & QRS relationship
– If P > QRS : Atrial arrythmia
– If P = QRS : Look for timing of P-wave
• P in QRS = AVRT
• P fused with QRS = AVNRT
– If P < QRS : Junctional arrythmia
50. Narrow complex tacchycardia
P in QRS
P = QRS = AVRT
WPW : Normal electrical conduction through AV AVRT with reentrance circuit consisting of 2 limbs,
node and accessory pathway cause slurred the antrograde limb involve the normal QRS and
upstoke of QRS wave (delta wave retrograde limbs involve accessory pathway
51. Narrow complex tacchycardia
P fused with QRS
P = QRS = AVNRT
AVNRT :Reentrance circuit around AV These AV nodal reentry beats stimulate both the atrium and the
nodeleading to rapid stimulation of ventricle ventricles rapidly in typically a 1 to 1 fashion with a strip of the EKG
and tacchycardia. shown at the bottom.
56. 2nd degree AV
Group of beat ?
block
PR segment
PR PR equal
Prolonger prolong
Morbitz I Morbitz II
57.
58. WINTER
2005
Brady &
Template
Tacchycardia
Panita Worapratya
Emergency Department
Prince of Songkhla University
59. Tacchycardia
•Assess & support ABCD
•Given oxygen
•Moniter EKG, BP, oxymetry
•Identify & treat reversible cause
Is patient stable ?
Yes Yes
•Establish AV access Immediate Synchronized
•Obtain 12 Leads EKG cardioversion
Is QRS narrow? (<0.12 s) Immediate I.V access
Expert consultation
If pulseless arrest develop, follow
guideline
60. Stable patient
•Establish AV access
•Obtain 12 Leads EKG
Is QRS narrow? (<0.12 s)
Narrow QRS complex Wide QRS complex
Regular or not?
Regular-narrow complex Irregular –narrow complex
•Attempt vagal maneuver Possible AF, atrial flutter or MAT
•Adenosine 6 mg iv push Consider expert consultation
then 12 mg iv push Controle rate : Diltiazem, B-blocker
may repeat 12 mg iv push at once Caution B-blocker in CHF, Hypotension
61. Regular-narrow complex
•Attempt vagal maneuver
•Adenosine 6 mg iv push
then 12 mg iv push
may repeat 12 mg iv push at once
Does rhythm convert ?
Rhythm Convert Rhythm Dose not Convert
= Possible SVT = Possible atrial flutter, ectopic atrial
•Observe for recurrent tacchycardia, or junctional tacchycardia
•Treat recurrent with adenosine or AV • Controle rate (diatiazem, b-blocker)
blocking agent (diltiazem/B-blocker) • Treat underlying cause
• Expert consultation
During evaluation consider
=6H= =5T=
Hypovolumia Toxin
Hypoxia Temponade
Hydrogen ion Thrombosis
Hypoglycemia Tension pneumothorax
Hypo/hyper kalemia Trauma
Hypothermia
62. Wide QRS complex
Regular Irregular
If atrial fibrillation with aberrency
If ventricular tacchycardia or uncertain
• Treat as irregular narrow complex
rhythm tacchycardia
•Amiodarone 150 mg i.v over 10 min
If preexite atrial fibrillation (AF with
Repeat as needed to maximum dose 2.2
WPW)
g/24 hr
• Expert consultation
•Prepare for synchronized cardioversion
• Avoid AV nodal blocking agent
If SVT with aberrency ,
(adenosine, digoxin, diltiazem,
•Give adenosine
verapamil)
• Consider antiarrhythmic drug
(amiodarone 150 mg iv over 10 min)
If recurrent polymorphic VT
• Expert consultation
If torsade de point give
•MgSO4 1-2 g over 5-60 min then
infusion
63.
64. • 35 yr-old woman with palpitation, light headness and stable
tacchycardia. EKG as picture. An IV has been established. What drug
should be administered IV?
o Atropine 0.5 mg
o Lidocaine 1 mg/kg
o Epinephrine 2-10 µg/kg/min
o Adenosine 6 mg
Answer : SVT =Adenosine 6 mg
65.
66. WINTER
Template
67 Yr-old male ไม่รู้สึกตัวมา 30 min >V/S : BP 64/24,PR 30/min หลังจากท่านได้ใส่
ท่อช่วยหายใจ เปิดเส้นเลือด ติด monitor EKG แล้ว คลื่นไฟฟ้าหัวใจเป็นดังรูปท่านคิดว่าการกระทาใด
เหมาะสมที่สุด
o On external pacing
o Atropine 0.6 mg iv stat
o 7.5 % NaHCO3 1 amp iv stat
o 10% Ca-gluconate 1 amp iv stat
67. WINTER
Template
55 Yr-old female บ่นจุกแน่นหน้าอกที่ลิ้นปี่มา 1 ช.ม เป็นขณะพัก ประวัติว่าเคยไปตรวจที่คลินิค
แพทย์บอกว่าหัวใจโต V/S : BP 140/86 PR 87/min ,regular-full peripheral
pulse. EKG เป็นดังรูป ท่านจะทาอย่างไร
o ให้ ASA, ISDN, Morphine
o ให้ serial EKG ไปก่อน รอ cardiac enzyme
o Consult cardiologist ทันที สงสัย AMI
68. WINTER
Template
58 Yr-old male บ่นแน่นหน้าอก หน้ามืดจะเป็นลม 30 นาที V/S BP 90/60 PR 33/min
,sweating, look anxiousness. EKG เป็นดังรูป ท่านจะทาอย่างไร
o ให้ atropine 1 amp iv. stat
o ให้ serial EKG รอ cardiac enzyme
o Consult cardiologist ทันที สงสัย AMI
o ใส่ Transcutaneous pacing
69. WINTER
Template
61 Yr-old male หน้ามืด ขณะนั่งรับประทานอาหาร ไม่มจุกแน่นหน้าอก แต่มีใจสั่น V/S แรกรับ
ี
BP 95/57 PR 42/min , irregular, sweating ถามตอบไม่รู้เรื่อง
o ให้ atropine 1 amp iv. stat
o ให้ serial EKG รอ cardiac enzyme
o Consult cardiologist ทันที
o ใส่ Transcutaneous pacing
70. WINTER
Template
66 Yr-old male, underlying CAD with history of coronary bypass
graft. มาด้วยเป็นลมหมดสติ ไม่รู้สึกตัว BP วัดไม่ได้ ปลายมือปลายเท้าซีด เย็น
o ให้ adenosine 6 mg iv stat
o ให้ synchronized cardioversion 100 J
o ให้ cordarone 150 mg iv stat
o ให้ Defib 200 J
71. • 57 yr-old woman with palpitation, chest discomfort and tacchycardia.
The moniter as picture. She becomes diaphoretic and BP 80/60
mmHg. The next action is
o Obtain 12 lead EKG
o Perform immediate electrical cardioversion
o Establish IV and give sedation for electrical cardioversion
o Give amiodarone 300 mg IV push
Answer : VT with pulse
Immediate electrical cardioversion
72. • If the patient is monomorphic, unstable VT
but has pulse, treat with synchronized
cardioversion initial dose is 100J. and
stepwise (200J, 300J, 360J)
73. • 27 ปีผู้ชาย อยู่ ๆ มีอาการใจสั่น หน้ามืด จะเป็นลม เหงื่อแตก ไม่เคยเป็นเช่นนี้มาก่อน
มาที่ ER ปลายมือปลายเท้าเย็น BP 120/84 PR 210 EKG เป็นดังรูป จงให้การรักษา
o Adenosine 6 mg iv stat
o Give amiodarone 300 mg IV push
o Perform immediate Defibrillation
o Establish IV and give sedation for synchronized cardioversion
74. WINTER
2005
Coronary
Template
Syndrome
Panita Worapratya
Emergency Department
Prince of Songkhla University
75. WINTER
2005
Basic EKG for
Template
ACS
Panita Worapratya
Emergency Department
Prince of Songkhla University
82. Basic Leads group
WINTER
Template
Wall EKG Blood supply
Inferior wall II, III, aVF RCA or LCA
RV infarction II, III, aVF, V4R Prox. RCA
83. Basic Leads group
WINTER Template
Wall EKG Blood supply
Inferior wall II, III, aVF RCA or LCA
RV infarction II, III, aVF, V4R Prox. RCA
Inf-Lat wall II, III, aVF, V5-6 Dominant RCA or LCA
88. Basic Leads group
WINTER
Template
Wall EKG Blood supply
Anterior V2-4 Mid LAD
Ant-Lat-Sep V1-6, aVL Prox LAD
Lateral I, aVL,V5,6 Diagonal branch of LAD
89. Basic Leads group
WINTERTemplate
Wall EKG Blood supply
Inferior wall II, III, aVF RCA or LCA
RV infarction II, III, aVF, V4R Prox. RCA
Inf-Lat wall II, III, aVF, V5-6 Dominant RCA or LCA
Anterior V2-4 Mid LAD
Ant-Lat-Sep V1-6, aVL Prox LAD
Lateral I, aVL,V5,6 Diagonal branch of LAD
90. RCA or RCx
WINTER
Template
RCA occlusion RCx occlusion
• ST elevation III > II • ST elevation II > III
• ST depression in Lead I • ST elevate in Lead I
• Isoelectric V4R • Negative V4R
91. Various cause of ST segment Deviation
ST elevation
WINTER ST depression
Template
Suggest
MI Symmetric ST
inversion in
contiguous leads
Asymmetric ST
Early “Scooping or strain
depression in
repolarization like pattern
lateral leads
93. Morphology of ST elevate
LVH LBB
WINTER
Pericarditis Hyper K+
Template
• Deep S wave in V1,V2
MI MI + RBBB Brugada
• Tall R in V5,V6
94. Morphology of ST elevate
LVH LBB
WINTER
Pericarditis Hyper K+
Template
MI MI + RBBB Brugada
• Predominate negative QRS in V1
• QRS widening > 0.12 s
• Upright QRS in Lead I, V6
95. Morphology of ST elevate
LVH LBB
WINTER
Pericarditis Hyper K+
Template
MI MI + RBBB Brugada
96. Morphology of ST elevate
LVH LBB
WINTER
Pericarditis Hyper K+
Template
MI MI + RBBB Brugada
97. Morphology of ST elevate
LVH LBB
WINTER
Pericarditis Hyper K+
Template
MI MI + RBBB Brugada
98. Morphology of ST elevate
LVH LBB
WINTER
Pericarditis Hyper K+
Template
MI MI + RBBB Brugada
99. Morphology of ST elevate
LVH LBB
WINTER
Pericarditis Hyper K+
Template
MI MI + RBBB Brugada
101. 1 Chest comfort
suggest of ischemia
2
EMS careand Hosp. preparation
• Moniter, ABC support, prepare for CPR & defibrillation
• Administer MONA (morphine,oxygen,nitroglycerine, ASA) as needed
• Obtain EKG, if ST-elevation
• Notify receiving hospital
• Begin fibrinolytic check list
• Notify hospital to response MI.
3
Immediate ED assessment < 10 min Immediate ED general treatment
• Check V/S, evaluate oxygen saturation Start O2 4 L/min, maintain O2 sat > 90%
• Obtain 12 leads EKG ASA 160-325 mg (if not given by EMS)
• Brief target Hx & PE NTG sublingual,spray or i.v
• Review fibrinolytic check list Morphine i.v if not improved by NTG
• Obtain initial cardiac marker level, E-lyte and
coagulopathy
• Obtain portable CXR < 30min
102. 4
Review 12 Leads EKG
5 9 13
ST depression or dynamic T-
Normal or nondiagnostic ST-
ST elevation or new LBBB wave, strongly suspected
wave change
Strongly suspected STEMI ischemia
Intermediate or low risk
UA high risk /NSTEMI
6 10 14
Start adjunctive treatment Start adjunctive treatment
as indicated as indicated Develop High or Intermediate
• B-adrenergic receptor block • Nitroglycerine risk criteria (Table 3,4)
• Clopidogrel • B-adrenergic blocker or
• Heparin • Clopidogrel Troponin positive
• Glycoprotein Iib/IIIa YES
No
≥ 12hr
7 11 15
Admit to moniter and Consider admission to ED
Time form onset of
risk assessment (Table chest pain unit or
symptoms ≤ 12 hr
3,4) monitered bed
• Serial cardiac marder
• Repeate EKG
< 12hr
• consider stress test
103. 4
Review 12 Leads EKG
5 9 13
ST depression or dynamic T-
Normal or nondiagnostic ST-
ST elevation or new LBBB wave, strongly suspected
wave change
Strongly suspected STEMI ischemia
Intermediate or low risk
UA high risk /NSTEMI
6
Start adjunctive treatment
as indicated
• B-adrenergic receptor block
• Clopidogrel
• Heparin
≥ 12hr
7 11
Admit to moniter and
Time form onset of
risk assessment (Table
symptoms ≤ 12 hr
3,4)
< 12hr
104. 7
Time form onset of
symptoms ≤ 12 hr
8
Reperfusion therapy
•Reperfusion goal
•Door to balloon (PCI) <
90 min
•Door to needle
(fibrinolysis) 30min
•Continue adjuctive
therapy and..
• ACE-I or ARB < 24 of
onset
• HMG co A reductase
inhibitor
105. 4
Review 12 Leads EKG
5 9 13
ST depression or dynamic T-
Normal or nondiagnostic ST-
ST elevation or new LBBB wave, strongly suspected
wave change
Strongly suspected STEMI ischemia
Intermediate or low risk
UA high risk /NSTEMI
10
Start adjunctive treatment
as indicated
• Nitroglycerine
• B-adrenergic blocker
• Clopidogrel
• Glycoprotein Iib/IIIa
11
Admit to moniter and
risk assessment (Table
3,4)
106. 11
Admit to moniter and
risk assessment (Table
3,4)
12
High risk patient (table 3,4 for
risk stratification)
• Refractory ischemic chest pain
• Recurrent persistent STE
• Ventricular tacchycardia
• Hemodynamic instability
• Early invasive strategy, including
PCI and revascularization for shock
≤ 48 hr. of AMI
Continue ASA, heparin and other
therapy as indicated
• ACE-I/ ARB
• HMG co A reductase inhibitor
107. 4
Review 12 Leads EKG
5 9 13
ST depression or dynamic T-
Normal or nondiagnostic ST-
ST elevation or new LBBB wave, strongly suspected
wave change
Strongly suspected STEMI ischemia
Intermediate or low risk
UA high risk /NSTEMI
14
Start adjunctive treatment
as indicated Develop High or Intermediate
• Nitroglycerine risk criteria (Table 3,4)
• B-adrenergic blocker or
• Clopidogrel Troponin positive
• Glycoprotein Iib/IIIa YES
No
15
Admit to moniter and Consider admission to ED
risk assessment (Table chest pain unit or
3,4) monitered bed
• Serial cardiac marder
• Repeate EKG
• consider stress test
108. 15
Consider admission to ED
chest pain unit or
monitered bed
• Serial cardiac marder
• Repeate EKG
• consider stress test
16
Develop High or
Intermediate risk
criteria (Table 3,4)
or
Troponin positive
17
If no evidence of
ischemia or infarction,
can discharge with F/U
109. Check list for STEMI fibrinolytic therapy
Step 1 Chest discomfort > 15 min, < 12 hr
YES
EKG show STEMI or new LBBB ? stop
YES
Are there contraindication for fibrinolysis ?
Step 2
SBP > 180 mm Hg □ YES □ NO
DBP > 110 mmHg □ YES □ NO
∆ Rt. VS Lt. arm SBP > 15 mmHg □ YES □ NO
History of structural CNS disease □ YES □ NO
Significant closed head or facial trauma < 3 mo □ YES □ NO
Recent major surgery or trauma or GU/GI bleed < 6 wk □ YES □ NO
Bleeding or clotting problem □ YES □ NO
CPR > 10 min □ YES □ NO
Pregnant female □ YES □ NO
Serious systemic disease □ YES □ NO
110. Check list for STEMI fibrinolytic therapy
Are there contraindication for fibrinolysis ?
Step 2
NO
Step 3 Is a pateint any high risk ?
If any of following check “YES” , consider PCI
HR ≥ 100/min and SBP < 100 mmHg □ YES □ NO
Pulmonary edmema (rale) □ YES □ NO
Sign of shock (cool, clamy) □ YES □ NO
Contraindication for fibrinolytid therapy □ YES □ NO
111. Table 3 : Likely hood of ischemic etiology (short term risk)
Part I : Chest pain patient without ST segment change
Likelihood of ischemic etiology
A : High likelihood B : Intermediate likelihood C : Low likelihood
Any of following No A with any of following No A & B with any of following
History • Chief complaint of Lt. arm
pain or discomfort plus
Current pain reproduce pain
of prior pain document
angina and Known CAD
including MI
Physical Exam • Transient MR
• Hypotension
• Diaphoresis
• Pulmonary edema or rale
EKG • New (or persume new)
transient ST deviation (>0.5
mm) or T wave inversion (> 2
mm) with symptoms
Cardiac marker • Elevate troponin I or T
• Elevate CK-MB
112. Table 3 : Likely hood of ischemic etiology (short term risk)
Part I : Chest pain patient without ST segment change
Likelihood of ischemic etiology
A : High likelihood B : Intermediate likelihood C : Low likelihood
Any of following No A with any of following No A & B with any of following
History • Chief complaint of Lt. arm • Chief complaint is Lt. arm pain
pain or discomfort plus or dyscomfort
Current pain reproduce pain • Age > 70 yr.
of prior pain document • Male sex
angina and Known CAD • Diabetic mellitus
including MI
Physical Exam • Transient MR • Extravascular disease
• Hypotension
• Diaphoresis
• Pulmonary edema or rale
EKG • New (or persume new) • Fixd Q wave
transient ST deviation (>0.5 • Abnormal ST segment or T
mm) or T wave inversion (> 2 wave that are not new
mm) with symptoms
Cardiac marker • Elevate troponin I or T • Normal
• Elevate CK-MB
113. Table 3 : Likely hood of ischemic etiology (short term risk)
Part I : Chest pain patient without ST segment change
Likelihood of ischemic etiology
A : High likelihood B : Intermediate likelihood C : Low likelihood
Any of following No A with any of following No A & B with any of following
History • Chief complaint of Lt. arm • Chief complaint is Lt. arm pain • Probable ischemic symptoms
pain or discomfort plus or dyscomfort • Recent cocaine use
Current pain reproduce pain • Age > 70 yr.
of prior pain document • Male sex
angina and Known CAD • Diabetic mellitus
including MI
Physical Exam • Transient MR • Extravascular disease • Chest discomfort reproduce
• Hypotension by palpation
• Diaphoresis
• Pulmonary edema or rale
EKG • New (or persume new) • Fixd Q wave • Normal EKG or T wave
transient ST deviation (>0.5 • Abnormal ST segment or T flattening or T wave inversion
mm) or T wave inversion (> 2 wave that are not new in leads which dominant R
mm) with symptoms wave
Cardiac marker • Elevate troponin I or T • Normal • Normal
• Elevate CK-MB
114. Table 3 : Likely hood of ischemic etiology (short term risk)
Part II : Risk of death or non fatal MI over the short term in Patient with chest pain with high
or intermediate likelihood of ischemia (column A, B in Part I)
High risk Intermediate risk Low risk
Any of the following Any of the following Any of the following
History • Accelerating tempo of ischemic
symptoms over prior 48 hr.
Character of pain • Prolong continue > 20 min of
rest pain
Physical exam • Age > 75 yr
• Pulmonary edema secondary to
ischemia
• New or worse MR
• Hypotension,
brady/tacchycardia
• S3 gallops or new or worsening
rale
EKG • Transient ST segment deviation
(≥ 0.5 mm with rest agina)
• Persume new LBBB
• Sustain VT
Cardiac marker • Elevate cardiac troponin
• Elevate CK-MB
115. Table 3 : Likely hood of ischemic etiology (short term risk)
Part II : Risk of death or non fatal MI over the short term in Patient with chest pain with high
or intermediate likelihood of ischemia (column A, B in Part I)
High risk Intermediate risk Low risk
Any of the following Any of the following Any of the following
History • Accelerating tempo of ischemic • Prior MI or
symptoms over prior 48 hr. • Peripheral artery disease or
• Cerebrovascular disease or
• CABG, prior ASA use
Character of pain • Prolong continue > 20 min of rest • Prolong > 20 min rest angina is now
pain resolved (moderate to high likely
hood of CAD)
• Rest angina (<20 min) or relieved
by rest or sublingual nitroglycerine
Physical exam • Age > 75 yr • Age > 70 yr
• Pulmonary edema secondary to
ischemia
• New or worse MR
• Hypotension, brady/tacchycardia
• S3 gallops or new or worsening
rale
EKG • Transient ST segment deviation (≥ • T wave inversion ≥ 2 mm.
0.5 mm with rest agina) • Pathologic T wave or Q wave that
• Persume new LBBB are not new
• Sustain VT
Cardiac marker • Elevate cardiac troponin • Any or above , plus normal
• Elevate CK-MB
116. Table 3 : Likely hood of ischemic etiology (short term risk)
Part II : Risk of death or non fatal MI over the short term in Patient with chest pain with high
or intermediate likelihood of ischemia (column A, B in Part I)
High risk Intermediate risk Low risk
Any of the following Any of the following Any of the following
History • Accelerating tempo of ischemic • Prior MI or
symptoms over prior 48 hr. • Peripheral artery disease or
• Cerebrovascular disease or
• CABG, prior ASA use
Character of pain • Prolong continue > 20 min of rest • Prolong > 20 min rest angina is now • New onset functional angina (Class
pain resolved (moderate to high likely III or IV) in past 2 wk. without
hood of CAD) prolong rest pain (but with
• Rest angina (<20 min) or relieved moderate to high likelihood of CAD)
by rest or sublingual nitroglycerine
Physical exam • Age > 75 yr • Age > 70 yr
• Pulmonary edema secondary to
ischemia
• New or worse MR
• Hypotension, brady/tacchycardia
• S3 gallops or new or worsening
rale
EKG • Transient ST segment deviation (≥ • T wave inversion ≥ 2 mm. • Normal or unchanged EKG during
0.5 mm with rest agina) • Pathologic T wave or Q wave that an episode of chest discomfort
• Persume new LBBB are not new
• Sustain VT
Cardiac marker • Elevate cardiac troponin • Any or above , plus normal • Normal
• Elevate CK-MB
117. Table 4 : TIMI risk score for patient with UA and NSTEMI
Risk factor of CAD
• Family Hx of CAD
Predictor variable • HT
• Hypercholesteralemia
• D.M
Age > 65 year • Current smoker
≥ 3 risk factor of CAD
ASA used in Last 7 days
≥ 2 angina event in last 24 hr
Recent , severe symptoms of angina
Elevated cardiac marker
ST deviation ≥ 0.5 mm.
Prior coronary a. stenosis > 50% •ST depression > 0.5 mm is
significant
•Transient ST deviation > 0.5
mm < 20 min is high risk
•STE > 1 mm (>20 min) =
STEMI
118. Table 4 : TIMI risk score for patient with UA and NSTEMI
Calculated Risk of ≥ 1 Risk status
TIMI risk primary end
score point in 14
days
0-2 5-8% Low
3-4 13-20% Intermediate
5 26% High
6 or 7 41% High
Predictor variable
Age > 65 year
≥ 3 risk factor of CAD
ASA used in Last 7 days
Recent , severe symptoms of angina
Elevated cardiac marker
ST deviation ≥ 0.5 mm.
Prior coronary a. stenosis > 50%
120. Case Presentation
A : Anxiousness.
WINTER
Template
B : Lung is clear . O2 sat วัดไม่ได้
C : PR 40/min,irregular rate, no murmur. Poor
peripheral pluse, acrocyanosis.
D : E3V5M5-6 No moter weakness.
124. Case Presentation
Initial management
WINTER
Template
A : None
B : O2 cannular 3 LPM
C : Moniter EKG, I.V access
ส่ง Lab + cardiac enzyme
0.9 % NSS iv load 1000 ml iv freee flow 300 ml Atropine 1
amp iv stat
On External pacemaker
125. Case Presentation
WINTER
Template
หลัง Load fluid ครบ 300 ml และให้ atropine 1 amp
V/S : PR 65/min BP 72/47 , O2 sat 100%
เริ่มถามตอบไม่รู้เรื่อง มองไม่สื่อความหมาย
Mx : ET-Tube No 7.5 ขีด 23 cm.
EKG เป็นดังรูป (next slide)
126. Case Presentation
WINTER
หลัง Load fluid ครบ 300 ml และให้ atropine 1 amp
Template
V/S : PR 65/min BP 72/47 , O2 sat 100%
เริ่มถามตอบไม่รู้เรื่อง มองไม่สื่อความหมาย
Mx : ET-Tube No 7.5 ขีด 23 cm.
132. Case Presentation
WINTER
Template
หลังจากท่านได้ Defibrillation แล้ว EKG เป็นดังนี้ ท่านจะทาอย่างไร
o Atropine 1 amp iv stat
o External pacemaker
o Transfer to ICU
o Load 0.9% NSS
133. WINTER
2005
Thank You
Template
Panita Worapratya
Emergency Department
Prince of Songkhla University
138. 04
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140. 4
Review 12 Leads EKG
5 9 13
ST depression or dynamic T-
Normal or nondiagnostic ST-
ST elevation or new LBBB wave, strongly suspected
wave change
Strongly suspected STEMI ischemia
Intermediate or low risk
UA high risk /NSTEMI
6 10 14
Start adjunctive treatment Start adjunctive treatment
as indicated as indicated Develop High or Intermediate
• B-adrenergic receptor block • Nitroglycerine risk criteria (Table 3,4)
• Clopidogrel • B-adrenergic blocker or
• Heparin • Clopidogrel Troponin positive
• Glycoprotein Iib/IIIa YES
No
≥ 12hr
7 11 15
Admit to moniter and Consider admission to ED
Time form onset of
risk assessment (Table chest pain unit or
symptoms ≤ 12 hr
3,4) monitered bed
• Serial cardiac marder
• Repeate EKG
< 12hr
• consider stress test